Case study: implementing the recommendations of the Tier 4 review Rachel Bryant-Waugh 22 nd October 2015
Eating Disorders (CYP) • Taking conclusions and recommendations of Tier 4 review forwards Autumn statement: £30m recurrently • Develop evidence based community Eating Disorder services for children and young people: capacity in general teams released to improve self-harm and crisis services. www.england.nhs.uk
Eating Disorders (CYP) • Access and waiting time standard and commissioning guidance for children and young people with an eating disorder (August 2015) • http://www.england.nhs.uk/resources/resources-for-ccgs/#local-trans • Systematic approach to: • Improving service delivery • Implementing evidence of what we know works • Improving outcomes • Reducing the need for in-patient stays www.england.nhs.uk
Eating Disorders (CYP) • NCCMH Expert Reference Group developed: • Access and waiting time standard • Referral to treatment pathways • Model for delivery of dedicated community eating disorder services for children and young people (CEDS-CYP). • Commissioning guide with workforce calculator published to support local commissioners with transformation. Chair: Peter Fonagy; Clinical lead: Rachel Bryant-Waugh; Commissioning lead: Andrew Roberts www.england.nhs.uk
Clinical context Chart 6.12: Hospital admissions for eating disorders, 10-24 year olds by gender, England 2013/14 http://www.youngpeopleshealth.org.uk/key-data-on-adolescence (chapter 6; pg 110)
Clinical context • HSCIC estimated rising admissions for ED: 8% rise reported between 2011/12 and 2012/13; biggest rise in 15 to 19 age group (HSCIC, 2014) • Incidence study showed number directly affected by ED increased significantly between 2000 and 2009 with an annual incidence rate of 164.5 per 100,000 of girls aged 15 to 19, more than double the rate for other ages (Micali et al., 2013; 2015) • Treasure and Russell (2011) found that unless intervention is delivered in first 3 years outcome is poor www.england.nhs.uk
Current challenges • Capacity to meet demand (rising need and reduction in capacity); variability in provision; inadequate liaison with schools, LA, colleges, healthcare provider • 6% of mental health budget spent on children and young people’s mental health care • Poor recognition of: - Risks - Understanding eating disorders (for all professionals, parents, young people) - Awareness of local care pathways, how to access help - Delay in accessing appropriate treatment for eating disorder – not meeting thresholds, decisions to refer being based on BMI YP: ‘ you get stuck between you are too severe to access community treatment … and you are not severe enough for inpatient treatment’
Evidence base • Most cost effective treatment reported to be delivered by a dedicated community-based eating disorder service as opposed to generic CAMHS (Byford et al., 2007); provision shown to: • Improve outcomes through reduction in relapse • Reduce need for inpatient care • Reduce disruption to school, family, social life • Eating disorder NICE guideline (2004) • Evidence-based family interventions • Family members including siblings should normally be involved in treatment www.england.nhs.uk
Evidence base • Update of ED NICE guideline (due 2017) cannot be anticipated but surveillance review on which the decision to update the guideline was made outlined need to consider: • Efficacy of day vs inpatient care • Role of family interventions and recommendations related to more formalised family therapy • Efficacy of CBT and enhanced CBT-E in the treatment of AN, BN and related adolescent presentations • Use of guided self-help for some presentations of BN • Role of pharmacological treatments – evidence suggests it is unlikely to be recommended as first-line intervention for treatment of eating disorders www.england.nhs.uk
Eating Disorders (CYP) Access and waiting time standard • Those referred for assessment or treatment for an eating disorder should receive NICE concordant treatment within one week for urgent cases and within 4 weeks for every other case. • Introduced and monitored in 2015-16 via MHSDS; tolerance levels to be set and standard implemented from 2017-18 • Aim is for 95% of those referred for assessment or treatment receive NICE concordant treatment with the ED standard RTT by 2020
Eating Disorders (CYP) Education • Eating disorder curricula group being convened in partnership with HEE (first meeting October 2015) building on: - Systemic family practice curriculum for eating disorder - Whole team training packages for multi-disciplinary community eating disorder services/teams - Modality specific evidence based interventions in line with updated eating disorder NICE guideline to be published in 2017
Community Eating Disorders Services • Population-based: minimum 500K (all ages) so may span more than one CCG • Referrals for AN, BN, binge eating disorders and co-existing problems (e.g. anxiety and depression) – multidisciplinary ED team able to respond to range of varying levels of need and severity • Min of 50 referrals per year to support viability • Enable direct access to community eating disorder treatment via self-referral, GPs, schools, colleges and voluntary sector, and support early identification through improved awareness, liaison and consultation • Maintain clinical oversight throughout the care path including inpatient admissions www.england.nhs.uk
Community Eating Disorders Services Expected benefits of CEDS-CYP model are for every child and young person with an eating disorder • Swift access to appropriate evidence-based eating disorder treatment from first and early identification of eating disorder; offering treatment to varying levels of presenting need • Improved access and reduction in waiting times • Treatments for eating disorder and co-existing MH problems delivered by one eating disorder team • Improved outcomes as indicated by sustained recovery, reduction in relapse, and reduced need for admission www.england.nhs.uk
Community Eating Disorders Services For children and young people and their families: • Clear access to help and advice when first concerned • Better collaboration in treatment and parents’ and carers’ being able to support and better understand the eating disorder and treatment • Reduction in need for long periods of treatment • Reduce disruption to school and family life • Increased involvement in commissioning of services that meet their needs www.england.nhs.uk
Models for Structuring Community Eating Disorder Services Model A A single team based together that provides the entire service for a geographical footprint Model B A team that operates via a network of smaller eating disorder teams in neighbouring areas via a hub and spoke model-but will need to function as one service meeting need across geographical area, working together for review and case management Submission of plans: CYP Transformation Plans need to demonstrate how monies for eating disorders are used to enhance or develop CEDS-CYP or, where CEDS-CYP are in place how any underspend or release in capacity will be used to benefit those who self harm or are in crisis.
Discussion • Specifics of what is expected to be delivered is the main focus • Emphasis on interventions not staffing • Three pronged approach to evidence based practice: • Research evidence; CYP and family values and preferences; clinician expertise/observation • Period of skilling up needed – training and post- training support needs • Place for development of networks – e.g. clinical support networks www.england.nhs.uk
www.england.nhs.uk
Transformation plans will need to • Be Transparent – publishing • Baseline investment by local commissioners • What services are provided including workforce information • Referrals received, accepted, waiting times • Demonstrate Service transformation in line with principles covering • range and choice of treatments and interventions available; • collaborative practice with children, young people and families and involving schools; • use of evidence-based interventions; and regular feedback of outcome monitoring to children, young people and families and in supervision. • Monitor improvement • Development of a shared action plan and a commitment to review, monitor and track improvements with appropriate governance structures. www.england.nhs.uk
Local Plans should • Cover the spectrum of services including community eating disorder services – focus on prevention to interventions, for existing or emerging mental health problems, as well as transitions between services. • Include local leadership and governance arrangements to secure a whole system approach to delivery at local level • Demonstrate collaborative commissioning within and across sectors to promote effective joint working and establish clear pathways. This includes working with collaborative commissioning groups in place between NHS England specialised commissioning teams and CCGs • Demonstrate that schools are given the opportunity to contribute to the development of Transformation Plans. • Be coherent with local priorities, and the child mental health requirements in the existing joint planning guidance. www.england.nhs.uk
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